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Patient/parent will Knowledge deficit verbalize R/T pre-op care. understanding of pre& post-op care. Potential infection R/T surgical procedure.
No aspiration.
Potential Normal parameters for alteration of vital patient's vital signs functions R/T established. surgery.
1. Obtain baseline assessment of all systems & N/V status within 8 hours pre-op. 2. Assess V.S. within 2 hours preop.
Nursing Intervention 1. Implement postoperative teaching program. 2. Document response. 1. Explain procedures. 2. Provide time for questions, expression of concerns and fears. 3. Offer reassurance. 1. Assess breath soundsHR/RR at least q shift. 2. Turn, cough and deep breathe q2 hrs. 3. Record vital signs. 1. Assess for pain and medicate per protocol.
Patient and family will cope effectively with surgical post-operative process.
Potential respiratory Patient will not experience compromise R/T respiratory compromise. general anesthesia. Alteration in comfort R/T Patient will verbalize/demonstrate
surgery.
2. Reposition for comfort as ordered/prn. . 1. Assess surgical site or affected extremity for color, capillary refill, sensation, temperature, pulses and active/passive ROM as ordered. 2. Document neurovascular status as ordered. 3. Report any neurovascular compromise to M.D. 4. Position extremity with elevation if ordered. 5. Apply ice or heat as ordered.
1. Monitor I/O q hour with IV or foley. 2. Begin ice chips or clear liquids slowly as ordered. 3. Maintain IV fluids as ordered. 4. Call M.D. for catheter order if unable to void after surgery. 5. Assess GU status q shift.
1. Mobilize as ordered. 2. Administer laxative of choice or suppository for no BM after 3 days. 3. Assess GI status q shift. 1. Assess skin q shift. 2. Provide daily nursing care.
Potential alteration Patient will not experience in skin integrity R/T skin breakdown. immobility.
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